Quantitative Component:
A total of 323 medical students out of 510 and 35 medical teachers out of 71 have responded voluntarily. Informed consent (through online google-forms) has been collected from all participants. [Figure-1]
A total of 323 students (Mean age: 20 years, SD:1.66; Male: Female = 1.78/1) were approached for inclusion in the study from this a total of 313 students provided consent for inclusion in the study. Finally, a total of 280 students were included in the study. Rest was excluded due to self-declaration of the presence of chronic diseases or addiction to the internet. From the 280 students include in the study, the mean age of the participants was 20 years with a median of 20 years and the age ranging from 17 years to 32 years. 36% of the participants were females and the rest were male.
The majority of students agreed to the fact that they faced technical difficulties during online classes. However, there was a significant difference in the issues between the male and female students. More than half of the students agreed that their doubts were not resolved satisfactorily during online teaching. However, there was a significant difference in response between male and female students. The majority of the students disagreed with the fact that their quest for knowledge increased after online teaching. When asked about the impact of online learning on self-confidence on the subject, most of the students responded that they have less confidence in the topics covered in the online classes. As per their response, the majority of students were not able to understand the topics in the online class and not able to learn practical skills. The majority were not able to connect effectively to their peers and teachers in the online classes. However, students disagreed with the statement that “online learning is more stressful than offline learning”. The detailed description of the questions asked and responses obtained were described in Table-1. When students were asked to rate the online learning and assessment on a scale of one to five, the mean score given was 2.3 (+/- 1.28) for learning and 2.28 (+/- 1.34) for online assessment. [Figure-2]
A total of 35 teachers were approached for the study, and from this 30 agreed to participate in the study. Among them 10 were female and the rest were male. The mean age of the participant teachers was 38.4 with a SD of 3.9.
When teachers were asked about the efforts required majority agreed that more planning and less timing are required for preparation. According to the response of the majority of teachers Online teaching methods are monotonous, hardly deliver skill competency and it is difficult to get student feedback during online classes. Majority of the teachers not agreed with the statement that the skill assessment is possible online. Most of the teachers agreed with the sentence that training is required to develop technical expertise in conducting online teaching. The detailed description of the questions asked and responses obtained were described in Table-2. When teachers were asked to rate the online teaching and assessment on a scale of one to five, the mean score given to the teaching was 2.10 (+/- 1.21), and for assessment was 2.03 (+/- 1.27) out of five. [Figure-3]
Qualitative Component:
After going through the individual transcripts verbatim several times, five broad themes were identified. The derived themes are Learning environment, Technology, Competency, Health issues, and Assessment. These have been presented in Figure-4 and explained below.
Theme-1: Learning environment:
The learning environment was one of the key areas that the majority of the students and teachers focused on during the discussion. Based on the information received, the following subthemes were identified:
Subtheme-1: Physical presence
Students described lack of communication (both verbal and nonverbal) with teachers as a major drawback of online academic sessions which leads to a lack of understanding of learning modules, diminished interest in academic sessions, and an increased number of absentees.
One student responded “Due to lack of eye-to-eye contact, it is impossible to understand anything” [Male student, 18 years]
“We are learning from the teacher in the offline class, seeing (his/her) expressions, and interests, we can guess the favorable time to ask doubts. But we feel hesitant in interrupting teachers in between ongoing online lectures, we can’t see expressions, the mood of teachers.” [Male student, 20 years] This comment emphasized the nonverbal communication between the teacher and students which helps students to learn better.
Some students emphasized that the act of teaching in physical class or teachers’ individual teaching style engages them better, which facilitates learning. For example, one participant commented:
“A teacher in a physical class, just draws a simple diagram on board, we can grasp more (than online teaching)” [Male student, 19 years]
Two students have shared opposite views in asking doubts in online sessions. One feels hesitant in asking doubts as teachers’ expressions are not visible, other one feels easy as it’s a matter of switching the mike on.
“Teachers are available after the class (offline), so we can clarify our doubts personally. Now we have to ask doubts by email which will be discussed in the next class only.” [Female student, 19 years]
“All are there in the class (offline) and I have to stand and ask doubts, but online I can ask a question by just switching my mike on.” [Male student, 18 years]
This feeling of missing the physical presence of the teacher is echoed by the teachers also who also think that the presence of students makes the class more interesting for them to teach. One teacher said, “I don’t get interested in teaching (online), it seems like speaking to a wall” [Female Teacher, 38 years].
They also felt that feedback through verbal and nonverbal communication makes the offline class more lively than the online class. “Non-verbal expressions, body language is not communicated (in online sessions), teaching is not like news... we are acting like news-anchors,” one teacher said [Male Teacher, 42 years].
Another teacher added “Most of the time we don't know actually the students are listening or not, he may be switching it on and sleeping also.... we don’t get any feedback... we are just talking to the screen, forwarding slides...” [Male teacher, 36 years].
One teacher compared the online and offline classes and said “Teaching at lecture theater has its own aura. Everyone is present, and remains attentive at 9 am for a good lecture. Online sessions never have that effect.” [Male teacher, 42 years]
One student identified the positive aspect of Online teaching i.e. multitasking during the class which is not possible in offline teaching. “I feel the classroom environment is monotonous… online sessions can be attended with home comfort…along with food and others.” [Female student, 20 years]
Subtheme-2: Distractors:
Participants were asked about their experience of learning at home in online media. Some students have reported a lack of ‘attention’ in the home environment creates difficulty in understanding critical concepts. They get more distracted by the presence of other family members. For example:
“It’s difficult to hold attention in online lectures. I can't hold attention throughout the lecture, feel distracted, sleepy as no learning environment has been generated” [Male student, 18 years]
‘I can grasp easily classroom teaching, sitting in a particular posture. Home comfort makes it difficult to understand the concept” [Female student, 21 years].
Getting a separate study area at home is another issue mentioned by a student. According to one student, “There are other family members at home doing household work (home distractions). I am not alone at home. I have asked all to keep quiet when switching my mike on.” [Male student, 19 years]
Subtheme-3: Peer interactions and competitive environment:
The majority of participants mentioned that lack of peer interactions is another major issue that brings a lack of motivation and competitiveness in the study. One student commented “In hostels or at the dissection hall, we used to have lots of discussions (peer interaction) and get prepared for the classes but in online (academic session), alone in the home, we miss that part… brings lack of seriousness in studies” [Female student, 19 years]. According to another student, “There was a healthy competition, when we are together, even during the class (offline). When someone is asking doubts, I feel, I also have to study and ask my own doubts” [Male student, 19 years]
One male student has shared his previous experience with online learning. “I have studied online during preparation for NEET (medical entrance examination) and cracked it. I prefer to study in isolation at that time but now I need to be more practically sound than only having theoretical knowledge. Group interaction is more important for me now which is not possible in online sessions” [Female student, 19 years]
Theme-2: Technology:
Technology is one of the important enabling factors in many health and health-related problems. In education, specifically in medical education, its role is recognized in India recently with the pandemic. Students have discussed both positive and negative points on this theme. We have divided it into two sub-themes.
Subtheme 1: Technical factors:
Students have identified some of the important positive points of online classes. Students mostly responded that the daily hassles of attending early morning lectures, and the incidence of skipping breakfast or late entries in classes are minimized with online classes. “A few morning classes are missed as we wake up late in the morning… that is not happening (in online sessions). Even if feeling sick, still can attend the class” a student [Male Student, 20 years] told. Another student [Male Student, 19 years] told “I usually miss 8 am to 9 am class more frequently. Now we can even enter (join online) at 8:30 am” [Male, 19 years]. The burden of taking class notes is less as recorded lecture sessions can be played multiple times for reference. A student told, “Burden of writing all the class notes is less as we can take screenshots”. This statement emphasizes the importance of online classes in reducing the burden of the classical system of teaching. The reach of online classes is wide according to the students. Even in illness or stuck in unavoidable circumstances, they were able to attend class.
“Internet issues are common… During a crucial moment of understanding critical concepts (during online sessions) or at the time of attendance… it becomes a major issue” [Female Student, 21 years].
“Our anatomy dissection classes and clinical postings are affected the most. I can't understand much; online videos are blurry. Spatially head & neck dissections are affected. Practical as a whole is not effective in (online mode teaching).” [Female Student, 21 years]
Teachers also have a similar view to that of the students. The use of technology during the class by the students was poor. Very few used this to connect with the teachers during the class. One teacher said: “The options for chat is not effective (for communication in online sessions). Hardly one or two students have ever communicated.” [Male teacher, 39 years]
Few teachers emphasized the fact that there is a serious lacking of training courses on the use of technology for teachers and students to make the classes more interactive. According to a Male teacher (36 Years), “Training for faculty, as well as students, is lacking (regarding online platform) to deal with technical issues. “
Subtheme 2: Financial factor:
Few students and teachers have emphasized the financial issues associated with technology use such as the cost of daily data or devices used. One student described “often, we are running out of data, sometimes video streaming is there in class… I sometimes prefer to stay at the hostel as its (internet) free” [Male student, 20 years]
Theme-3: Health issues:
Few students talked about their health issues associated with regular online sessions. Online sessions increase screen time significantly and also promote a sedentary lifestyle and other health effects. Few students talked about insomnia-like effects, eye-straining, excess watering of the eye, and headache. A student told “Online sessions leads to sedentary lifestyle. What happened with me is that I can’t sleep well at night but during offline sessions, I usually get tired attending lectures, and practical sessions and getting good sleep. Some kind of insomnia I faced at home” [Male student, 18 years]
Another comment by a female student “My screen time had increased much, I had some headache and watering in eyes as well” [Female student, 21 years]
Theme-4: Competency:
Another crucial point highlighted by the students is their concern about the lack of skill development in practical sessions and lack of confidence in the modules taught online. There are two important subthemes arose within the theme.
Subtheme 1: Skill:
All students discussed the difficulty of learning practical skills in an online learning format. According to one student, “I didn't get motivated in online practical sessions as we don't have to perform that. It feels like theory only” [Male, 18 years] Another student added “I have not visited medicine and OBGY (obstetrics and Gynecology) clinical posting for a single day (offline). Nervous system examination sessions of Physiology subject are conducted online” [Male, 20 years]. Like the students, teachers are also skeptical about the skill and knowledge development of students. One teacher said: “It's my duty to take classes, I am paid for that...I will put more effort so that the final output is good, but in online classes, I knew (have experience) the output will not be good, even if I put my full efforts.” This shows less confidence in teachers as a whole in online classes.
Subtheme 2: Knowledge:
The poor confidence in knowledge among the students got reflected in the following sentence “I don't have much confidence in the modules covered online compared to offline. I feel a lack of confidence… as we have an offline assessment on the topics taught online during the first year… I feel a serious difficulty…” [Female student, 21 years] This shows the lack of confidence in the student in the topics covered in online sessions.
Theme-5: Assessment
Students have mentioned some other advantages of online sessions, such as getting easy attendance and engaging in other important tasks in parallel with attending lectures. Few students have raised issues related to online assessments and parents' concerns about online sessions. All students expressed positive views regarding offline examinations/assessments. They feel motivated to perform and feel satisfied with their grades. They are not feeling confident enough in online assessments. The ‘seriousness’ of the examination is somewhere lacking. “Our online examination has only MCQ type of questions but offline has multiple types of written questions as well. We can score more in MCQs. We are happy with the scores but do not feel satisfied at the end of the examination. The environment of examination is absent in online assessments” [Male student, 21 years]
Teachers have pointed out another factor regarding the validity of the online assessment. “I fill like, online assessment, I have done it lots of time, they (students) can easily cheat.... we don't have any control, over whether they had open books or not. They can speak and even can communicate through online media (during examination)”